Accelerometer-measured physical activity and posture among older adults in assisted-living residences.

Objective: Few studies have detailed the physical activity and postural patterns (e.g. lying or sitting) in older adults with declining activities of daily living (ADL). Therefore, we aimed to address this issue by quantifying physical activity using an accelerometer and measuring time spent in various postures among older adults in assisted-living residences. Methods: We quantified physical activity using an accelerometer (ActivPAL) and measured time spent in various postures in 35 older adults (mean age: 89.1 years) with chronic conditions residing in two assisted-living residences in Japan. ActivPAL was attached to the thigh and trunk of patients to distinguish between sitting and lying postures. Results: Participants had a mean count of 6.2 comorbidities, and they were divided into three groups (fully independent, requiring minimal assistance and requiring care) based on their activities of daily living capacity using the Barthel Index. Residents aged ⩾90 years walked a mean of 1109.1 steps and spent 167.3 min upright per day. Fully independent participants walked a mean of 3587.6 steps daily; those requiring minimal assistance walked 1681.0 steps daily; and those requiring care walked 428.9 steps daily. Conclusions: Our findings indicated that step count, number of sit-to-stand transitions, stepping time, and upright time decreased significantly as activities of daily living capacity decreased. Comorbidity type and number of comorbidities were not related to their lying time except for depression status. Lying time was associated with depression status.

Adrenal Insufficiency Following Prolonged Administration of Ultra-High Topical Steroid: A Case of Refractory Dermatitis.

Replacement of a usual medication with a remarkably effective medication might result in a dramatic improvement for a specific disease. However, an abrupt change in medication might bring about other challenges. Herein, we report the case of an 84-year-old man who developed severe hyponatremia after the abrupt discontinuation of prolonged ultra-high topical steroid use. At the time of visiting the emergency department, he had been treating chronic eczema with the medication dupilumab for three months. We initially considered this newly started medication as the cause of the problem. However, dupilumab has not been reported to be connected to any electrolyte or endocrine disorder (e.g., syndrome of inappropriate anti-diuretic hormone secretion), and severe hyponatremia did not improve by the administration of high volume of NaCl. Thus, we reconsidered alternative causes for this hyponatremia and checked the patient's history of medication. He had been prescribed clobetasol propionate 0.05% by the dermatologist until one month before arriving at the emergency department. In addition, he had completely stopped using topical steroids for the last two weeks because his dermal condition had substantially improved. His cortisol level was low, substantiating a diagnosis of adrenal insufficiency. Hydrocortisone administration improved both hyponatremia and his symptoms. Therefore, when a patient with newly administered medication presents with new symptoms, we recommend that differential diagnosis include a medical review of the patient's last three months of medication and the conditions of use including how the topical agents were used.

A Case of Acute Cerebral Infarction With Chief Complaints of Abdominal Pain and Bloody Diarrhoea: The Power of a Patient-Centered Inclusive Diagnostic Team.

We present the case of a 66-year-old man who presented with acute abdominal pain and bloody stool as his chief complaints and was finally diagnosed with ischemic colitis from colon cancer and acute cerebral infarction. Although several cognitive biases led to physicians missing the presence of acute stroke, a diagnostic team consisting of the patient, his family members, a ward nurse, and the physician worked effectively to reach the correct diagnosis soon after admission. A physician is not the only person involved in the diagnostic process. A patient-centered diagnostic team is necessary.

Severe hypoglycaemia under abemaciclib administration in a patient with breast cancer: A case report.

The current study reports the case of an 80-year-old woman who experienced severe hypoglycaemia after abemaciclib administration, with a recovery time of ~46 h. Abemaciclib is a cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor that is used to treat metastatic breast cancer. A side effect of abemaciclib administration is an increase in creatinine levels. The half-life (t1 / 2) of 150 mg abemaciclib in patients with breast cancer was reported to be 17.5 h (nearly lower limit), and the time to reach Cmax was ~5 h (Tmax, 4-6 h). Therefore, the total time to reach half the maximum blood concentration after abemaciclib administration is ~24 h (Tmax + t1 / 2=5+17.5=22.5 h). As abemaciclib is administered twice daily, a considerable amount (Cmax = 123 ng/ml) may persist in the blood following the initial dose. Upon repeated administration, the blood abemaciclib concentration in patients with metastatic liver tumours might increase, although their liver function remains normal. The patient described in the current study had a creatinine level of 1.05 mg/dl at the start of abemaciclib administration. At the time of emergency hospitalisation (on day 5 of abemaciclib administration), the creatinine level was 1.40 mg/dl; however, dehydration was not observed. The patient had been administered the same dose of glimepiride for >1 year and had not experienced hypoglycaemia previously. It can be speculated that the increase in blood creatinine level had some effect on glimepiride metabolism. It is thought that administered abemaciclib enhances metabolic delay in the blood in the same way as in patients with impaired liver function, and as a result, the creatinine level increases in patients with liver metastases. This causes a decrease in renal function, which in turn results in an increase in blood concentration of glimepiride, consequently leading to severe hypoglycaemia. Therefore, clinicians must be careful when using abemaciclib in patients with liver metastases, diabetes and poor renal function.

Poorly Differentiated Gastric Adenocarcinoma Can Mimic Hilar Cholangiocarcinoma.

This report describes two cases with obstructive jaundice caused by poorly differentiated gastric adenocarcinoma. Computed tomography scans showed circumferential stenosis in the hilar bile ducts. Endoscopic retrograde cholangiopancreatography showed dilatation of the bilateral hepatic ducts and stenosis of the common hepatic ducts from the bifurcation of the bilateral hepatic ducts. The first diagnoses were hilar cholangiocarcinoma and biliary drainage decreased serum bilirubin; however, both patients died of cancer within a short period of time. Autopsies revealed lymphatic vessel invasion and possible subepithelial invasion by gastric adenocarcinoma into the hilar bile ducts. A differential diagnosis should thus be required in suspected cases of hilar cholangiocarcinoma.

Distinctive Patterns of Three-Dimensional Arterial Spin-Labeled Perfusion Magnetic Resonance Imaging in Subtypes of Acute Ischemic Stroke.

BACKGROUND: Ischemic penumbra in acute ischemic stroke (AIS) can be evaluated using arterial spin-labeled (ASL) perfusion magnetic resonance imaging (MRI). We used three-dimensional ASL-MRI to examine patients with different stroke subtypes and the clinical utility of the method within 24 hours of AIS onset. SUBJECTS AND METHODS: The 55 male and 48 female patients (mean age, 79.0 years) underwent diffusion-weighted imaging (DWI), fluid-attenuated inversion recovery imaging, magnetic resonance angiography, and pulsed continuous ASL perfusion imaging to determine stroke subtype, hypoperfused ASL area, and neurological deficit severity (National Institutes of Health Stroke Scale). Arterial transit artifacts, indicative of occlusive regions or collateral flow, and other stroke indices were compared. RESULTS: ASL hypoperfusion was detected in 3 of 9 patients with transient ischemic attack (TIA), 2 of 27 patients with lacunar infarction (LI), 19 of 31 patients with atherothrombotic infarction (AT), and 30 of 36 patients with cardiogenic embolic infarction (CE). ASL abnormalities were significantly less frequent in LI than in AT and CE, and more frequent in CE than in TIA. ASL abnormalities were more prevalent in patients with medium-to-large DWI-assessed lesions than in those with small lesions on DWI. Patients with medium-sized lesions following AT and CE had a high frequency of diffusion-perfusion mismatch. In 4 of the 5 patients who underwent intravenous thrombolytic therapy, ASL hypoperfusion and diffusion-perfusion mismatch were improved and the occluded arteries were recanalized. CONCLUSIONS: ASL perfusion studies may provide useful clinical information allowing diffusion-perfusion mismatch detection and treatment selection in AIS patients, depending on stroke subtype.

[Assessment of the vulnerable elders survey as a predictive test for elderly patients with advanced or metastatic gastric cancer treated with combined S-1 and docetaxel therapy].

Ten patients aged 75 years or more with advanced or metastatic gastric cancer were prescribed S-1 plus docetaxel (DOC) combination therapy. None of the patients showed complete response, but 2 showed partial response and 4 showed stable disease. Grade 3 or 4 toxicities occurred in 3 patients. Three patients with performance status (PS) 1 achieved partial response or stable disease and were free of Grade 3 or 4 toxicities, whereas the response and occurrence of adverse events in 7 patients with PS 2 varied widely. In these patients, an investigation of the relationship between response to treatment and the Vulnerable Elders Survey (VES-13) score showed that VES-13 scores were higher in the non-response group than in the other patients and in patients who experienced adverse events than in those who did not. These findings suggest that VES-13 could be a useful screening tool for predicting response and the occurrence of adverse events in elderly patients undergoing combined S-1 plus DOC therapy for advanced or metastatic gastric cancer.

Polyarteritis nodosa diagnosed by surgically resected jejunal necrosis following acute abdomen.

The differential diagnosis of acute abdomen is typically extremely broad in range, with vasculitis posing a rare but potentially life-threatening cause of acute abdomen. Here, we report a case of acute abdomen with bowel wall thickening limited to jejunum, accompanied by unexplained renal dysfunction. Later, the patient was diagnosed as having polyarteritis nodosa based on surgically resected jejunal necrosis. Despite aggressive treatment, including the use of steroid pulse therapy and continuous hemodiafiltration, the patient died. Although polyarteritis nodosa is extremely rare in patients with acute abdomen, acute abdomen is relatively common manifestation of that. And it is reported that involvement of small intestine suggests poorer prognosis. Our case highlights the importance of vasculitis as a differential diagnosis of patients with atypical acute abdomen. In this report, we not only review possible clues that might have led to an earlier diagnosis in this case, but also attempt to draw some lessons for treating similar cases in the future.

Inflammatory myofibroblastic tumor causing ileoileal intussusception: an unusual cause of an unusual neoplasm in an adult, with a clinicopathological review of the literature.

An inflammatory myofibroblastic tumor (IMT) of the ileum is a very rare lesion of the gastrointestinal tract. A 36-year-old female presented with abdominal fullness and colicky pain of 5 days' duration. Plain abdominal radiography showed an intestinal obstruction with dilated jejunal loops. Abdominal computed tomography and ultrasonography demonstrated a well-defined intraluminal solid mass surrounded by the typical mural layers of an invaginated ileum. The patient then underwent an exploratory laparotomy under a clinical diagnosis of intussusception caused by a small bowel tumor. The surgical findings revealed a large mass leading to an ileoileal intussusception, with regional lymph node enlargement and a small bowel resection accompanied by lymph node dissection was performed. The definitive diagnosis of IMT was confirmed by both conventional histopathology and minute immunohistochemistry.

Somatosensory disinhibition and frontal alien hand signs following medial frontal damage.

We report augmentation of somatosensory evoked potentials (SEP) in a patient with frontal alien hand signs after left medial frontal lobe damage. The SEP components occurring later than 30 msec post stimuli were enhanced over the parietal and frontal scalp sites of the lesioned hemisphere. This finding suggests that deficits in inhibitory control of somatosensory processing in parietal and frontal lobes contributes in some way to frontal alien hand signs.

Impaired novelty processing in apathy after subcortical stroke.

BACKGROUND AND PURPOSE: Apathy is associated with decreased novelty-seeking behaviors and is a prevailing behavioral symptom after stroke affecting cortical and subcortical regions. We studied the relationship between apathetic state after subcortical stroke and neural orienting response to novel events using an event-related evoked potential (ERP) technique. METHODS: Twenty-nine patients with subcortical ischemic stroke were grouped according to whether they showed apathy or not. We analyzed apathy state scaled by the modified Starkstein apathy score and auditory P3 ERP components evoked by task-relevant target stimuli (target P3) and task-irrelevant novel stimuli (novelty P3). RESULTS: The apathetic group showed a significantly lower score of verbal fluency test and global cognitive function test compared with the nonapathetic group. The novelty P3 latency was significantly prolonged, and its amplitude was reduced over the frontal site in the apathy group. The apathy scale was correlated with the novelty P3 latency and amplitude at the frontal site. The target P3 measures were related to global cognitive function. CONCLUSIONS: The present study suggests that apathy after subcortical stroke is associated with impaired neural processing of novel events within the frontal-subcortical system and that the novelty P3 is a useful physiological measure for assessing apathy after stroke.

Transthyretin Thr60Ala Appalachian-type mutation in a Japanese family with familial amyloidotic polyneuropathy.

A Japanese case with familial amyloidotic polyneuropathy (FAP) associated with the transthyretin mutation Thr60Ala (Appalachian-type mutation) is described This is the first reported case of a non-Caucasian harboring this type of TTR mutation. The patient developed severe late-onset restrictive cardiomyopathy as well as sensorimotor and autonomic polyneuropathy, which were essentially similar to the previously reported clinical pictures of Appalachian-type FAP.